A nurse is evaluating the pain level of a toddler who is cognitively impaired to a nonpharmacologic intervention. Which of the following pain scales should the nurse use to evaluate the toddler's pain level?
Visual analog
FACES
FLACC
CRIES
The Correct Answer is C
Rationale:
A. Visual analog scales rely on the child's ability to comprehend and interpret visual cues, which may be challenging for a cognitively impaired toddler.
B. FACES scales require the child to identify their pain level based on facial expressions, which may also be challenging for a cognitively impaired toddler.
C. FLACC (Face, Legs, Activity, Cry, Consolability) scales are specifically designed for non-verbal or cognitively impaired individuals, assessing pain based on observable behaviors such as facial expression, leg movement, activity level, cry, and ability to be consoled.
D. CRIES scales are primarily used for assessing pain in newborns and infants and may not be as applicable for a cognitively impaired toddler.
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Related Questions
Correct Answer is D
Explanation
A. A heart rate of 54/min is within the normal range for a 5-year-old child and does not specifically indicate hemorrhage.
B. Flushing of the face is not a direct indicator of hemorrhage.
C. A blood pressure of 95/56 mm Hg may be within the normal range for a 5-year-old child and does not specifically indicate hemorrhage.
D. Continuous swallowing can indicate bleeding in the postoperative period following a tonsillectomy and adenoidectomy, as blood may be pooling in the throat and swallowed rather than expectorated.
Correct Answer is A
Explanation
A. This finding is consistent with both acute laryngotracheobronchitis and pneumonia, as both conditions can cause discomfort and distress in children.
B. Fever can be present in both acute laryngotracheobronchitis and pneumonia as they are both infections of the respiratory tract. It is a non-specific symptom that can occur with various respiratory illnesses.
C. This finding is more consistent with acute laryngotracheobronchitis than pneumonia, as acute laryngotracheobronchitis is characterized by a barking, non-productive cough that worsens at night or with agitation, while pneumonia causes a productive cough that may be accompanied by chest pain or difficulty breathing.
D. This finding is more consistent with acute laryngotracheobronchitis than pneumonia, as acute laryngotracheobronchitis causes inflammation and narrowing of the upper airway, leading to a high-pitched sound during inhalation, while pneumonia affects the lower airway and does not usually cause stridor.
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